Related Experiment Video
Updated: Aug 31, 2026
The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire
Published on: December 23, 2014
Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters
W Schummer1, S Herrmann, C Schummer
1Department of Anaesthesiology and Intensive Care Medicine, Friedrich-Schiller-University of Jena, Bachstrasse 18, D-07743 Jena, Germany. cwsm.schummer@gmx.de
Insights
Electrocardiogram (ECG) guidance for central venous catheter (CVC) placement is less reliable on the left side. Left-sided CVC placement frequently requires repositioning and post-procedure X-rays to ensure correct positioning.
Area of Science:
- Medical Devices
- Cardiology
- Interventional Radiology
Background:
- Central venous catheters (CVCs) are commonly positioned using ECG guidance.
- A higher incidence of perpendicular catheter tip angles was observed with left-sided CVC placement.
- This study investigated the efficacy of left-sided ECG guidance for CVC positioning.
Purpose of the Study:
- To evaluate the reliability of ECG guidance for left-sided internal jugular vein catheterization.
- To compare the accuracy of ECG guidance with other methods for CVC tip confirmation.
- To determine the incidence of malpositions with left-sided CVC placement.
Main Methods:
- A prospective study randomized 114 patients to right (53) or left (61) internal jugular vein catheterization.
- Three ECG-guided insertion depths (ID-A, ID-B, ID-C) were recorded.
- Final catheter tip position was confirmed using transesophageal echocardiography (TOE) and chest X-ray (CXR).
Main Results:
- Insertion depths varied significantly with left-sided ECG guidance (P<0.001).
- 84% of left-sided CVCs required repositioning for adequate aspiration.
- 13% of left-sided CVCs were malpositioned, with 9 undetected by ECG guidance.
Conclusions:
- Intra-atrial ECG guidance is unreliable for confirming left-sided CVC position.
- ECG guidance fails to detect the superior vena cava-right atrium junction.
- Post-procedural CXRs are recommended for left-sided CVCs, but not right-sided ones.
Background:
ECG guidance is widely used for positioning central venous catheters (CVCs) in the superior vena cava. We noticed a higher incidence of a more perpendicular angle between the catheter tip and the vessel wall after left-sided ECG-guided catheter positioning. To investigate the value of left-sided ECG guidance, we performed this prospective study.
Methods:
Of 114 patients, 53 were randomized to right and 61 to left internal jugular vein catheterization using a triple lumen catheter. Three methods to ascertain catheter tip position were sequentially applied in each patient, and the insertion depths (ID) obtained using each of the three methods were recorded: (i). ECG guidance with a Seldinger guide wire (ID-A); (ii). ECG guidance with saline 10% used as an exploring electrode (ID-B); (iii). from position ID-B, the catheter was rotated and advanced until all three lumina could be aspirated easily. The catheter was fixed in that position (ID-C). To determine final catheter tip position, intraoperative transoesophageal echocardiography (TOE) and a postoperative chest X-ray (CXR) were performed.
Results:
The depth of insertion of a catheter using the three methods varied significantly in left-sided (P<0.001), but not in right-sided catheters. Forty-eight of 57 (84%) left-sided CVCs, correctly positioned according to ECG guidance, had to be advanced further to achieve free aspiration through all three lumina. By this stage, five of the catheter tips had been positioned in the upper right atrium as demonstrated by TOE. There were 13 malpositions (23%) after left-sided insertion. In nine catheter malpositions, undetected by ECG guidance, the angle between the catheter tip and the lateral wall of the superior vena cava exceeded 40 degrees on CXR.
Conclusions:
Intra-atrial ECG does not detect the junction between the superior vena cava and right atrium. It is not a reliable method for confirming position of left-sided CVCs. Post-procedural CXRs are recommended for left-sided, but not right-sided CVCs.
Related Concept Videos
01:21Cardiac Catheterization II: Right Heart Catheterization
01:24Cardiac Catheterization III: Left Heart Catheterization
01:28Electrocardiogram Fundamentals
An electrocardiogram (ECG) is a diagnostic tool for identifying cardiac conditions such as arrhythmias, conduction abnormalities, and myocardial ischemia.
Definition
An electrocardiogram (ECG) visualizes the heart's electrical activity by tracing the electrical movement associated with each heartbeat on a graph or monitor. As the heart beats, an electrical wave passes through it, correlating with the cardiac cycle events.
Parts of an ECG
An ECG utilizes electrodes on the skin to...
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias
01:28Cardiac Catheterization I: Pre-Procedure Overview
01:29Venous Thrombosis III: Interprofessional Care